Age-related eye disease: potential benefits of supplements, nutrition

DALLAS – Here at the Southwest Council of Optometry meeting, Primary Care Optometry News gathered a group of clinicians to compare their approaches to counseling patients on the role of nutrition and supplementation in preventing or slowing the progression of age-related eye diseases. The panelists discussed antioxidants, zinc and omega-3s and their effect on eye disease, including dry eye.

ROUNDTABLE PARTICIPANTS
James D. Colgain, OD, FAAO, is the clinical director for Whitten Laser Eye in Washington. He is also a lieutenant colonel with the Air National Guard.	Bruce E. Onofrey, OD, RPh, FAAO, is director of primary eye care services, Lovelace Medical Center, Albuquerque, N.M., and a Primary Care Optometry News Editorial Board member.	William Townsend, OD, practices at Advanced Eye Care in Canyon, Texas, and is a consultant at the VAMC in Amarillo, Texas.
Gary E. Oliver, OD, FAAO, is the regional clinical director for TLC Laser Eye Center in Plymouth Meeting, Pa.	Leo P. Semes, OD, FAAO, is an associate professor of optometry at the University of Alabama at Birmingham School of Optometry, and a Primary Care Optometry News Editorial Board member.	Robert S. Vandervort, OD, FAAO, is the center director for the Omaha Eye & Laser Institute in Omaha, Neb.

Primary Care Optometry News: Let’s discuss the dietary and supplemental intake of antioxidants and the prophylaxis of age-related eye disease. Which antioxidants do you feel play a role?

Bruce E. Onofrey, OD, RPh, FAAO, FOGS: The Age-Related Eye Disease Study (AREDS) looked at 500 mg of vitamin C, 400 IU of vitamin E, 15 mg of beta carotene, 80 mg of zinc and 2 mg of copper. Patients taking these supplements were found to have an 8% decrease in progression of age-related macular degeneration (AMD) from category 3 to 4 and a 19% reduced loss of visual acuity in category 3.

Gary E. Oliver, OD, FAAO: Both during AREDS and prior to AREDS, zinc was looked at for its antioxidant capabilities in AMD. However, practitioners need to be careful with the dosing of zinc. At high levels, zinc can cause toxicity and depletion of copper.

Leo P. Semes, OD, FAAO: The 80 mg of zinc per day used in the AREDS is a pretty high dose.

William Townsend, OD: And it’s important to remember that we should avoid beta carotene in smokers.

Dr. Oliver: Beta carotene should be avoided in anyone at risk for lung cancer, which also includes people with exposure to asbestos.

Dr. Townsend: And these are the people, especially the smokers, who have an increased risk for macular degeneration.

Dr. Semes: While some people say that beta carotene should only be avoided in current smokers, others say it should even be avoided after patients have stopped smoking for 5 or 10 years.

Proof of prevention?

James D. Colgain, OD, FAAO: If I have a 50-year-old patient who has parents with macular degeneration or a 45-year-old with a small amount of drusen, is there proof that giving antioxidants will slow progression?

Dr. Townsend: I don’t think there’s actually proof that it’s preventive.

Dr. Semes: Cho and colleagues, in a study published in the June 2004 issue of Archives of Ophthalmology, concluded that fruit intake was inversely associated with the risk of neovascular age-related maculopathy (ARM). However, they said that intake of “vegetables, antioxidant vitamins or carotenoids were not strongly related to either early or neovascular ARM.” The study involved nearly 80,000 women and more than 40,000 men at least 50 years old with no diagnosis of ARM or cancer.

Dr. Oliver: In terms of prevention, you’re really looking at lutein intake with antioxidants.

Robert S. Vandervort, OD, FAAO: What is everyone suggesting for patients with a normal macula but a family history of AMD?

Dr. Colgain: I tell patients that while we cannot draw the conclusion that supplements prevent progression, in the proper dosage they will not hurt you, and they may have protective effects.

Dr. Townsend: However, it’s important to remember that none of these are without side effects or interactions. For instance, I’m quick to tell people about the benefits of dark green leafy vegetables. But we’ve got to remember to tell people who are on a platelet-inhibiting drug that these vegetables can diminish the effect of these medications.

Dr. Vandervort: I always tell patients to inform their family physicians about any supplements I ask them to take. It’s important to keep everyone in the loop.

Dr. Semes: It’s been recommended that eye care practitioners should ask all patients about the use of vitamins and herbs, because a study by West and colleagues published in the March 2005 issue of the American Journal of Ophthalmology found that 58% of 397 patients surveyed took daily vitamins, while 8% of them used herbal products on a daily basis. According to the study, 26% learned about vitamins from their primary care physician and only 2% from their ophthalmologist, while 35% discussed their use with their primary care physician and 5% with their ophthalmologist.

Dr. Townsend: If a patient has macular degeneration that has reached the edge of the macula, is there any reason to tell him or her not to take supplements? I know doctors who are still recommending these for patients who are 20/400, with no macula left. Is it judicious or ethical to continue to prescribe these vitamins? Some of these people are on limited budgets, and these vitamins are not inexpensive.

Dr. Colgain: If it’s not going to hurt them, I let them continue.

Dr. Vandervort: This population of patients is so vulnerable. They’re devastated by this disease, and they go from doctor to doctor. If you tell them not to take supplements, in essence, you’re kind of acquiescing to the disease. The patient is likely to switch to another practitioner unless you’re being aggressive in low vision. They’re searching for the magic cure, and they’re desperate.

Dr. Oliver: Remember that AREDS was fairly specific in the types of patients in whom benefits can be seen. Early prevention was not something they documented.

Dr. Colgain: That’s a challenge. It did not address prevention, and it did not address the severe individuals. It slowed down the progression of the disease, but nothing reversed. Patients are looking for something to return their loss of vision.

Dr. Semes: Researchers in the United Kingdom conducted a literature search to determine what vitamins would make up an effective ocular supplement that would be “suitable for those with a family history of glaucoma, cataract or AMD or lifestyle factors predisposing onset of these conditions such as smoking, poor nutritional status or high levels of sunlight exposure” as well as those with early stages of age-related ocular disease. Hannah Bartlett and Frank Eperjesi concluded that vitamins C and E and lutein/zeaxanthin should be included in their “theoretically ideal ocular nutritional supplement” (Ophthal Physiol Opt 2004;24:339-349).

Dosages

PCON: What dosages of antioxidants would you recommend to your patients?

Dr. Vandervort: I recommend four Ocuvite or PreserVision (Bausch & Lomb) a day: two in the morning and two in the evening. Patients should not take more than 60 to 80 mg of zinc a day.

Dr. Townsend: It’s important to tell people not to take this on an empty stomach.

Dr. Semes: In terms of dosing, there are recommended daily allowances. In Centrum (Wyeth), for example, all the ingredients are at least the recommended daily allowance.

Dr. Oliver: I know several practitioners who recommend a Centrum a day and an Ocuvite or ICaps (Alcon) with lutein. Suggest one of each to make sure the patient is not neglecting his or her other nutritional needs.

Dr. Colgain: Also, as we live longer, the diseases that affect the aged are growing at an explosive rate. A 2004 National Eye Institute study looked at AMD doubling its incidence by the year 2020. As Americans, 4 million of us are turning 50 every year, and a macular degeneration disaster is going to be a part of our future in eye care unless we can prevent it in some way.

Dispensing

Dr. Vandervort: Should optometrists and ophthalmologists be dispensing supplements out of their offices?

Dr. Colgain: It would be easier to answer that question if revenue from these medications did not remain in the practice. In contrast, purchasing a supplement at Wal-Mart can be overwhelming, and patients often buy what is on sale, not what you recommend. For that reason, I think dispensing to the patient is reasonable. This would ensure that they take what you recommend. However, because revenue is involved, there could be an inclination to prescribe more than is appropriate.

Dr. Vandervort: Is there a difference in vitamin companies? Is one vitamin really going to be absorbed differently than a different vitamin? If there is a difference, it is our profession’s obligation to identify the right companies and the best vitamins and get those to our patients.

Dr. Semes: Different states have different regulations on what you can sell out of your office. For example, in Alabama, we have to charge sales tax on spectacles, while ophthalmologists do not. In Florida, you have to keep records of everything that you dispense out of your office. You have to have an inventory, and you have to have a log book. So it’s a little complex.

Omega-3s and dry eye

PCON: What do you tell your patients about omega-3s in the management of dry eye?

Dr. Townsend: It is estimated that our intake of omega-3s has declined 600% during the past 150 years. That’s an astonishing figure when you think that it’s an essential lipid. More and more evidence is showing that it’s very important in terms of the formation of anti-inflammatory mediators within the body.

Dr. Colgain: Trivedi and colleagues looked at dietary omega-3 fatty acid intake and the risk of dry eye in women. Omega-3 intake was validated by a food frequency questionnaire administered to 32,470 women, and dry eye syndrome was self-reported. The researchers said the results suggested that women with a higher dietary intake of omega-3s are at decreased risk of developing dry eye.

Dr. Townsend: We use omega-3 supplements primarily for the management of meibomian gland dysfunction, and we tell patients that they didn’t develop this disease over a period of months but over a period of years. Most people do benefit from omega-3 supplementation. It can decrease joint pain and help with constipation.

There are definitely side effects to these supplements, and the side effects can be communicated through handouts.

Dr. Onofrey: In a 3-year study, C.F. Boerner reported an 85% success rate of complete resolution of dry eye symptoms (burning and stinging) with flaxseed oil use, along with a marked decrease in artificial tear use.

Flaxseed oil can also improve contact lens intolerance, comfort during computer use, post-op LASIK comfort, meibomian oil quality and rosacea blepharitis. It does not help with drug-induced dry eye or in Sjögren’s patients. And avoid flaxseed oil in women with a history of breast cancer.

Dr. Colgain: Omega-3s take about 6 to 8 weeks to work. So, patients need to understand that it’s not going to be a miracle.

Omega-3s do benefit some dry eye patients, and they have been associated with some heart protection. The cost is $0.30 to $0.50 a day. If you can get dry eye above a level that’s symptomatic with an oral medication taken once a day, it’s much better than walking around with eye drops.

Dr. Townsend: The two enemies of the essential fatty acids are light and heat. So omega-3s need to be stored out of direct sunlight in a place that’s not too hot.

PCON: Are there any potential pitfalls of omega-3s?

Dr. Colgain: They have the potential to decrease clotting time and increase bleeding.

Dr. Townsend: If people are on Coumadin (warfarin, DuPont) or a similar drug, they can be more prone to bleed.

Dr. Vandervort: Of course, there are mercury issues with omega-3s coming from fish oil.

Dr. Townsend: That’s why we avoid fish oil and use flaxseed oil.

Dr. Semes: Remember that the Food and Drug Administration doesn’t control these supplements. There are not supposed to be any indications on the bottle for curing or preventing disease.

Dr. Colgain: For medications that are well studied, we would know the pitfalls, indications and contraindications. This is not the case with many nutraceuticals. When it says 200 mg, is that a variable of ±50 in an unregulated supplement?

Smoking, diet

PCON: What about lifestyle modifications in the prevention or treatment of age-related eye disease?

Dr. Semes: Macular degeneration has four alterable risk factors: smoking, blue light exposure, blood lipid levels and antioxidant and zinc levels. When you think about environmental exposure to blue light, we get most of it when we’re youngsters, so that’s the group that we really have to target.

Regarding diet and nutrition, zinc is probably number one in terms of minerals. Also important is a high-lipid diet.

Dr. Colgain: Recent studies have shown that statins do not prevent macular degeneration; however, patients on statins have fewer incidences of neovascular consequences of macular degeneration.

Dr. Vandervort: Statins are like the next aspirin.

Dr. Townsend: But they’re not without consequences.

PCON: What are the potential ocular pitfalls of trendy diets, such as Atkins and the South Beach diet?

Dr. Townsend: With the South Beach diet, there’s a trend back toward more vegetables. Rheumatologists are prescribing glucosamine and chondroitin for joint disease. People are realizing that we need to go back to eating more vegetables.

Dr. Vandervort: It all comes back to the old adage, “everything in moderation.” Most diets don’t last because people can’t stay on them. You need to change the lifestyle permanently for the diet to be effective. High protein, low cholesterol diets are not good for the brain.

With the Atkins diet, fruit is out.

Dr. Semes: Our medical history form specifically asks about diets, and it’s important to know which patients are on which diet.

For Your Information:

• Bruce E. Onofrey, OD, RPh, FAAO, FOGS, can be reached at Lovelace at Journal Center, 5150 Journal Center Blvd NE, Albuquerque, NM 87109 ; (505) 275-4226; fax: (505) 262-3366; e-mail: Eyedoc3@aol.com.
• Gary E. Oliver, OD, FAAO, can be reached at 600 W. Germantown Pike, Suite 160, Plymouth Meeting, PA 19462; (610) 940-3937; fax: (610) 940-9566; e-mail: Gary.Oliver@tlcvision.com.
• Leo P. Semes, OD, FAAO, can be reached at University of Alabama, 1716 University Blvd., Birmingham, AL 35294-0010; (205) 934-6773; fax: (205) 934-6758 ; e-mail: LSemes@icare.opt.uab.edu.
• William Townsend, OD, can be reached at 1801 4th Avenue, Canyon, TX 79015; (806) 655-7748; fax: (806) 655-2871; e-mail: drbill1@cox.net.
• James D. Colgain, OD, FAAO, can be reached at Whitten Laser Eye, 1133 20th St. NW, Ste., B-150, Washington, DC 20036; (202) 785-2435; e-mail: jcolgain@aol.com.
• Robert S. Vandervort, OD, FAAO, can be reached at 11606 Nicholas St., Omaha, NE 68154-4478; (402) 493-2020; fax: (402) 493-8987.